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SAN JOAQUIN LOCAL ,HEALTH DISTRICT - <br /> FOR OFFICE USE: 1601 E. Hazelton Av.e.�, Stockton, CA 95205 PermIssued it No. 79.7�1 _ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date V <br /> This PermitEx ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin-Local Health District for a permit to construct <br /> sand/or install the- work herein described. This application is made in compliance with San <br /> doaquin County Ordinance No: 1862.- and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSRIM CITY/TOWN <br /> k <br /> honeAOwner's Name Phone - <br /> Address-L :!.­ <br /> ddress: :!... - �� .� 1�:•r,,, Le;... <br /> C i ty ZsC. n.L o.v <br /> Contractor's Name sLicense#�.?79ajb ._ Phone -tea <br /> IS CERTIFICATE OF WORKMIAN'S COMPENSAT101I- I-NSURAIN0 --ON- F11LE_WITi1-=SJ1-HD.—VFS-------X­11 - <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEP..EN ❑ RECONDITION ❑ DESTRUCTION❑ ok o <br /> WELL CHLORINATION `o_ `WELL ABANDONMENT ❑ OTHER R1 <br /> PUMP INSTALLATION�.--PUMP-fI PAL _0__ PUMP_REP_LAC1 I ENT._[ __-� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL oQ(� <br /> INTENDED USE TYPE OF WELL''" _ -, tc. (CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool { I ` Dia":of well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of'Casing <br /> Irrigation Gravel Pack Depth of'Grout Seal, <br /> Cathodic Protection Rotary Type of Grout <br /> `Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: ContractorT,, D. St, Mon f,� 0A,, <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Works Done.1w :, r) <br /> PUMP REPAIR: --C7State.-Wor-k--0 I --E----- _ _ <br /> DESTRUCTION OF WELL: WellaDiameter r6 d tv Approximate Depth 0' <br /> Describe` Materi an Proc Jure <br /> I hereby certify that I have prepate.d this application and that the work will be done in accordanc <br /> , with San Joaquin County Ordinances , `State Laws , and Rules andiRegulations of the- San Joaquin Local <br /> � Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performanc-e.. df-„ the work for which this permit is issued, I shall <br /> f not employ any person in such manner as to become subject 'Ito Workman's Compensation <br /> laws of California. ” <br /> I WILL CALL FOR A G UT INSPECTION PRIOR TO GROUTING AND A FINA INSPECTION. <br /> SIGNED TITLE: DATE: �a" �79 <br /> DR W PLOT PL N' ON REVERS SIDE <br /> FOR D PARTM T USE ONLY <br /> '. PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> JADD1710NAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE/ DATE 79 <br /> '�31/7 8 2M. <br /> ru 1AIM" n_., <br />